Non-surgical Management of Blunt Splenic Trauma: A Comparative Analysis of Non-operative Management and Splenic Artery Embolization-Experience from a European Trauma Center.

PURPOSE: The objective of our study was to retrospectively compare the outcomes of non-operative management (NOM) and splenic artery embolization (SAE) in the management of hemodynamically stable patients with splenic injuries. MATERIALS AND METHODS: In a 5-year period, 109 patients were recorded; 60/109 were treated with NOM and 49/109 with SAE. For each patient, the following parameters were assessed: Glasgow coma scale, injury severity score, American Association for the Surgery of Trauma splenic injury grade, transfusion requirements, hemoglobin level, presence of a splenic vascular lesion (SVL) and amount of hemoperitoneum (Bessoud scale). Different SAE techniques (proximal, distal, combined) with different materials were employed. Clinical success was defined as spleen conservation at 30 days; failure was defined as spleen re-bleeding within 30 days, requiring splenectomy. Student's t test or Chi-square analysis and the Kaplan-Mayer curve were used to analyse each group's results and compare them with those of the other group. RESULTS: In the SAE group, AAST splenic injury grade was higher and serum hemoglobin levels were lower. The SAE group had significantly more SVL and hemoperitoneum compared to the NOM group. The clinical success rate was not significantly different between groups (NOM = 95%, SAE = 87.8%; p = 0.16). Sixty-six percent of NOM failures were related to inadequate patient selection, while 67% of SAE failures were due to technical/procedural issues. CONCLUSION: Our study observed a high splenic salvage rate with the use of SAE as an adjunct to NOM, and suggests that it may be further improved with appropriate patient selection and an improved embolization technique.

Image-Guided Proper Liver Segmentectomy.

BACKGROUND: The new cross-sectional radiological tools, 3D computed tomography and magnetic resonance, allow a precise study of the liver anatomy. Thanks to these imaging techniques, a new space inside the liver parenchyma, the "hepatic core," was recently recognized, where the hila of liver segments are present. METHODS: On the basis of anatomical and radiological observations, we identified a new virtual plane of dissection, named "hepato-portal," which is useful in liver segmentectomy, if integrated with the classical planes of dissection. RESULTS: Simulated surgical procedures can be intra-operatively transferred by ultrasounds. In this way, we performed ten "proper" liver segmentectomies through preliminary sections of the hilar vessels and a precise dissection of the boundaries of each segment. CONCLUSIONS: Our experience underlines the value of integrating anatomy and radiology in the simulated liver surgery.

Putative clinical subtypes of social phobia: a factor-analytical study.

OBJECTIVE: To examine symptomatological subtypes of social phobia (SP) and their relationships with a number of feared situations and avoidant personality disorder (APD). METHOD: In 153 out-patients with SP according to DSM-III-R criteria, clinical subtypes were investigated by means of principal component factor analysis of the Liebowitz Social Anxiety Scale (LSAS). We compared the various SP subtypes on the basis of the highest Z-scores obtained on each LSAS factor. RESULTS: Five factors (interpersonal anxiety, formal speaking anxiety, stranger-authority anxiety, eating and drinking while being observed, anxiety of doing something while being observed) emerged, accounting for 64.7% of the total variance. When the dominant LSAS factor groups were compared, the highest values in the numbers of feared situations and the presence of APD were observed in the "interpersonal anxiety" dominant group and the lowest in the "anxiety of doing something while being observed". The "interpersonal anxiety" dominant group was the most likely to present a positive family history for SP and a lifetime comorbidity with mood disorders. CONCLUSION: The emerging multidimensional structure of phobia is congruent with, and further enriches, the existing literature.

The temporal relationship between anxiety disorders and (hypo)mania: a retrospective examination of 63 panic, social phobic and obsessive-compulsive patients with comorbid bipolar disorder.

BACKGROUND: The relationship between anxiety and depressive disorders has been conventionally limited to unipolar depression. Recent studies from both clinical and epidemiologic samples have revealed intriguing associations between anxiety and bipolar (mainly bipolar II) disorders. The present report examines the temporal sequence of hypomania to panic (PD), obsessive-compulsive (OCD) and social phobic (SP) disorders. METHODS: Specialty-trained clinicians retrospectively evaluated the foregoing relationships in 63 patients meeting the DSM-III-R diagnosis for PD, OCD and SP with lifetime comorbidity with bipolar disorders (87% bipolar II). Structured interviews were used. RESULTS: In nearly all cases, SP chronologically preceded hypomanic episodes and disappeared when the latter episodes supervened. By contrast, PD and OCD symptomatology, even when preceding hypomanic episodes, often persisted during such episodes; more provocatively, nearly a third of all onsets of panic attacks were during hypomania. LIMITATIONS: Assessing temporal relationships between hypomania and specific anxiety disorders on a retrospective basis is, at best, of unknown reliability. The related difficulty of ascertaining the extent to which past antidepressant treatment of anxiety disorders could explain the anxiety-bipolar II comorbidity represents another major limitation. CONCLUSIONS: Different temporal relationships characterized the occurrence of hypomania in individual anxiety disorder subtypes. Some anxiety disorders (notably SP, and to some extent OCD) seem to lie on a broad affective continuum of inhibitory restraint vs. disinhibited hypomania. By contrast, and more tentatively, PD in the context of bipolar disorder, might be a reflection of a dysphoric manic or mixed hypomanic symptomatology. The foregoing suggestions do not even begin to exhaust the realm of possibilities. The pattern of complex relationships among these disorders would certainly require better designed prospective observations.

Clinical experience using adjunctive gabapentin in treatment-resistant bipolar mixed states.

OBJECTIVE: Open studies and case observations have suggested that gabapentin may be effective in the treatment of bipolar disorder. However, the adjunctive use of the drug in bipolar mixed states has not been specifically addressed before. METHODS: Twenty-one patients with bipolar I mixed episodes as defined by Diagnostic and Statistical Manual of Mental Disorders (Revised) (DSM-III-R), who were admitted to the outpatient department at the Psychiatry Clinic of the University of Pisa, were treated adjunctively with gabapentin for a period of eight weeks. All patients had been resistant to therapeutic levels of standard mood stabilizers, and had a mean clinical global impression (CGI) of 5.2+/-0.8 when entering the study. Gabapentin treatment was started at 300 mg/day and increased up to 2000 mg/day. Patients were evaluated using the Hamilton Rating Scale for Depression (HRSD), the Young Mania Rating Scale (YMRS), and CGI. Patients with final CGI scores of 1 or 2 were regarded as responders. RESULTS: Only one patient had to interrupt the drug treatment, due to irritability and ataxia. Negative interactions between gabapentin and concomitant psychotropic medications were not observed. The condition deteriorated in only one patient (final CGI = 5). Ten patients were regarded as responders: four showed marked improvement (CGI = 1), and six had moderate improvement (CGI = 2). The mean dose of gabapentin at week 8 was 1130 mg (range 600-2000 mg). The mean final CGI score for all patients (responders and nonresponders combined) was 3.7+/-1.1 (the mean change in CGI was significant, t=6.1, P<0001). The reduction in the mania score was minimal and statistically insignificant. However, the mean HRSD score showed a statistically significant reduction from 18.2 to 10.6 (t=5.73, P<0.0001), irrespective of the baseline severity of the mania. All but one of the responders maintained these therapeutic improvements over 4-12 months, in most cases requiring less concomitant antidepressant and neuroleptic medications. CONCLUSIONS: These results show that gabapentin appears to be potentially useful in the adjunctive treatment of drug-resistant bipolar mixed states, and that it was particularly effective in relation to depressive symptomatology.

Avoidant personality in social phobia and panic-agoraphobic disorder: a comparison.

BACKGROUND: Avoidant personality disorder (APD) is generally believed to be related to social phobia (SP), especially to generalized subtype. However, it has also been reported to be prevalent in panic disorder-agoraphobia (PDA). In the present investigation, we wished to explore whether APD in each of these disorders has discriminatory features. METHOD: We studied 71 SP and 119 PDA patients with state-of-the-art clinical instruments based on DSM-III-R. RESULTS: The pattern of social avoidance in SP was more pervasive: it was characterized by a higher level of interpersonal sensitivity and greater severity, associated with psychopathology as well as a higher rate of Axis I comorbidity. By contrast, avoidance of non-routine situations characterized APD occurring in the setting of PDA. LIMITATIONS: Differences in inclusion criteria and comorbidity rates, as well as overlap between different operational disorders, may have influenced our findings. CONCLUSION: ADP is operationally broad, and 'avoidant' as a specifier of a personality type is insufficiently precise. ADP captures avoidant traits --which appear secondary to a core dimension such as interpersonal sensitivity--but is basically a heterogeneous condition influenced by the nature of comorbid Axis I disorders.

Prevalence of anxiety disorders comorbidity in bipolar depression, unipolar depression and dysthymia.

Eighty-seven patients with current episode of depression were assessed by the SCID-P and subdivided in bipolar depressives (N = 24), unipolar depressives (n = 38) and dysthymics (n = 25). Anxiety disorders comorbidity in these three groups was investigated by means of the SCID-P. Panic disorder comorbidity was found in 36.8% of bipolar depressives, 31.4% of unipolar depressives and 13% of dysthymics. Prevalence of obsessive-compulsive disorder was 21.1% in bipolars, 14.3% in unipolars and 8.7% in dysthymics. Generalized anxiety disorder resulted in being much more associated with dysthymia (65.2%) than with bipolar (31.6%) or unipolar depression (37.1%). Social phobia comorbidity was exhibited mainly by unipolars (11.4%), while no cases were detected in the bipolar group. Odds ratios revealed that generalized anxiety disorder is significantly more likely to co-occur with dysthymia. Panic disorder showed a higher trend to be associated with bipolar and unipolar depression. Social phobia was more frequent among unipolar depression.

Social adjustment in panic-agoraphobic patients reconsidered.

Forty-eight depressed panic-agoraphobic patients--clinically matched for severity of depression with 35 primary chronic depressives--had significantly better adjustment in most areas of social functioning, especially those related to interpersonal contact, work, leisure activities, and sexual life. Even when depressed, panic-agoraphobic patients appear to possess sufficient interpersonal skills--that is, by learning on significant others--to engage in a range of social activities, both at home and beyond. These data, which are open to different interpretations, nonetheless suggest that anxiety and mood disorders differently affect certain key areas of social adjustment.

Affective comorbidity in panic disorder: is there a bipolar connection?

Although theoretical explanations for comorbidity in panic disorder (PD) abound in the literature, the complex clinical challenges of these patients have been neglected, especially where panic, obsessive-compulsive and 'soft' bipolar (e.g., hypomanic, cyclothymic and hyperthymic) conditions might co-exist. The aim of the present study has been to systematically explore the spectrum of intra-episodic and longitudinal comorbidity of 140 DSM-III-R PD patients--67.1% of whom concomitantly met the criteria for Agoraphobia--and who were consecutively admitted to the ambulatory service of the Psychiatric Clinic of the University of Pisa over a 2-year period. Comorbidity with strictly defined anxiety disorders--i.e., not explained as mere symptomatic extensions of PD--was relatively uncommon, and included Simple Phobia (10.7%), Social Phobia (6.4%), Generalized Anxiety Disorder (3.6%), and Obsessive-Compulsive Disorder (4.2%). Comorbidity with Major Depression--strictly limited to the melancholic subtype--occurred in 22.9%. Comorbidity with Bipolar Disorders included 2.1% with mania, 5% with hypomania, as well as 6.4% with cyclothymia, for a total of 13.5%; an additional 34.3% of PD patients met the criteria for hyperthymic temperament. We submit that such comorbid patterns are at the root of unwieldy clinical constructs like 'atypical depression' and 'borderline personality'. The relationship of panic disorder to other anxious-phobic and depressive states has been known for some time. Our data extend this relationship to soft bipolar disorders. Studies from other centers are needed to verify that the proposed new link is not merely due to referral bias to a tertiary university setting.

Gender-mediated clinical features of depressive illness. The importance of temperamental differences.

In a consecutive clinical series of 538 subjects with primary mood disorders the male:female differences were most skewed (1:4) in recurrent unipolars, 1:2 in single episode and bipolar I subtypes, and about even (1:1) in bipolar II. The sexes did not differ in age at onset of depression, stressors preceding index episodes, endogenous features, psychotic symptoms, suicide attempts, and rates of chronicity. Females had lower mean number of hypomanic, and higher mean number of depressive, episodes. Females also exhibited more anxiety and somatisation, and were more likely to endorse psychopathological items on self-report instruments, which were not reflected in objective measures. Finally, they were more likely to have been admitted to hospital. These gender differences could in part be explained by the higher prevalence of the depressive temperament in women, and of the hyperthymic temperament in men.

Primary and secondary social phobia: psychopathologic and familial differentiations.

We compared "primary" social phobic patients (n = 25) with patients whose social phobia developing in the setting of panic disorder ("secondary" social phobics, n = 26) and panic-agoraphobic patients (n = 82). Familial, demographic, and symptomatologic data suggest a categorical distinction between the two types of social phobia. Secondary social phobics were essentially similar in all parameters to panic disorder with agoraphobia. These data support DSM-III conventions.